Provider Demographics
NPI:1184903064
Name:CHIROPRACTIC SPINE AND INJURY CENTER LLC
Entity type:Organization
Organization Name:CHIROPRACTIC SPINE AND INJURY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAUTEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-276-7002
Mailing Address - Street 1:784 BLANDING BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7724
Mailing Address - Country:US
Mailing Address - Phone:904-276-7002
Mailing Address - Fax:904-272-0086
Practice Address - Street 1:784 BLANDING BLVD STE 106
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7724
Practice Address - Country:US
Practice Address - Phone:904-276-7002
Practice Address - Fax:904-272-0086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty